From China to the U.S.—and back

I am a medical student enrolled in Peking University Health Science Center, Beijing,
China, but in the past year, I completed five months of clinical rotations in the
United States.

As a visiting medical student from China, one has to overcome a significant number
of difficulties. Let us look at them one by one.

Verbal English and medical English

Photo courtesy of Chi Tang.

Teaching in medical schools in China is almost completely carried out in Chinese.
Although a few English textbooks are recommended for certain courses, students use
Chinese textbooks as their primary study resources and examinations are largely based
on these books. As a result, students have very limited knowledge of medical English
and cannot pronounce most terminology correctly. In addition, most American schools
require a passing score on the United States Medical Licensing Examination (USMLE)
Step 1 to be eligible for rotation. This test is a huge challenge for students who
know very little medical English. Most medical graduates in China have to spend a
year to prepare for this exam. As a student from a top school in China, I am the only
student who passed the exam among my 200 classmates.

Verbal English is even more challenging, due to the fact that there are few English-speaking
people living in China and the majority of students have no opportunity to go abroad.
But most American schools either require a Test of English as a Foreign Language (TOEFL)
score of more than 23 in spoken English, or they conduct a telephone interview. These
barriers prevent the majority of students in China from even submitting an application.

Difference in curriculum system

Medical school curriculum varies greatly from school to school in China. In my school,
we have two pre-med years, 1.5 pre-clinical years and 2.5 clinical years. The difference
from American schools largely lies in the clinical years. First of all, there is no
primary care in China (at least in cities); patients go directly to specialists for
health care. As a result, we don't have general medicine, family medicine, or general
pediatrics rotations. For our medicine and pediatrics clerkships, we rotate through
a few selected subspecialties. For our family medicine clerkship, most of the time
is spent in lectures, combined with some observation at rural hospitals. Although
we do have a general surgery clerkship, students are assigned to rotate in a few selected
subspecialties of general surgery. In addition, most schools do not have family medicine,
emergency medicine and psychiatry clerkships at all, and neurology is incorporated
into the internal medicine clerkship. Furthermore, students obtain very little hands-on
patient care experience in clinical years and do “observerships” most
of the time; this is partly due to an increasing amount of lawsuits, which makes hospitals
fearful. It is also partly due to lack of incentives for teaching, as faculty members'
income is not related to the amount of time they spend in teaching. The result of
all these differences is that most students in China cannot fulfill the requirements
for American rotation, or find it extremely difficult to adapt to the new system when
they come to the United States.

Authorization from the home school

Obtaining authorization from one's home school is probably the most difficult step
for students in China. The majority of schools ban domestic students (they have different
policies for international students) from doing an away rotation because “away
rotation” is not included in their curriculum. Although there are a few schools
that send their students abroad for away rotations through official exchange programs
with the accepting schools, they all strictly forbid students from applying by themselves.
The whole authorization process took me eight months, during which time I talked to
many school officials and submitted multiple documents. Finally, I became the first
domestic student in my school authorized to apply for away rotations.

Limited choice of schools and rotation

The majority of American schools do not accept international visiting students. Those
that do accept them usually fill rotation spots with their own students first, then
other American visiting students. Next come the international students whose schools
have agreements with the American school. Other international students get the spots
that are left. The total number of schools that I was qualified to apply to was around
20 to 25. Though I submitted my application eight months ahead of time, many schools
were already filled by then. I applied to 18 schools, listing 4 to 5 choices of months
and approximately 10 choices of rotation for each school. In the end, I received 15
acceptance letters.

Immunization and other health requirements

Most American schools require antibody titer for hepatitis B, and some schools require
antibody titer for measles, mumps, rubella and varicella. Since people do not have
primary care physicians in China, I needed to go to a hospital that was able to do
these tests. The number of hospitals that can issue test reports in English is extremely
limited. Among these few hospitals, most are not able to measure antibody titers.
I contacted hospitals throughout Beijing and finally found one hospital that could
do the tests, but at a high price.

Application fee payment

Generally, application fees are paid by check or money order payable at American banks.
At first, I was very confused because I had no idea what a check was or how to use
it. After some research, I learned that I could open a checking account in a bank
and write checks. But American banks are not authorized to issue checks or money orders
in China. At the same time, individual Chinese citizens are not authorized to open
checking accounts in any banks. After a thorough search of banks in Beijing, I was
able to find a bank that cooperates with Citibank, such that money orders issued by
this bank are payable at Citibank. It took two business days to process a money order.
I had to travel to the bank about 20 times to buy and collect all the money orders
needed for applications.

Malpractice insurance

Schools in China do not provide malpractice insurance for students. (In fact, licensed
physicians do not have malpractice insurance either. Hospitals reimburse patients
for any malpractice incurred by their employees.) However, most American schools require
malpractice insurance for visiting students. I searched several Internet forums for
medical students and finally found a company that provides malpractice insurance for
international students.

Health insurance

A student's health insurance provided by the Chinese government does not cover health
care service abroad. I found a U.S.-based health insurance company and purchased the
insurance online.

Accommodations

Since I am a foreign citizen and I have never been to the U.S. before, I didn't have
a driver's license or credit record. In addition, I had to change my location every
month. It was very difficult to find an apartment that was within walking distance
from a hospital, furnished and rentable on a short-term basis, and did not require
a credit check. My strategy was to search all possible apartments on Craigslist and
contact the school's visiting student coordinator for more information.

Expenses

For one month of a U.S. rotation, my approximate expenses were $700 for an apartment,
$300-$400 for food, $50 for local transportation, and $100-$300 for an airplane ticket.
Other costs included $3,600 in total application fees (18 schools), tuition fees varying
from $0 to $3,700 per month, $1,200 for malpractice insurance, $300 for health insurance,
$144 for a visa, $500 for immunization and lab tests, $880 for the USMLE Step 1 registration
fee, $200 for the TOEFL registration fee, and $1,000 to $2,000 for a round-trip flight
between China and the United States. The total amount was about $14,000 for five months
of rotations. In contrast, tuition for my medical school is approximately $900 per
year. Even then, 30% of Chinese students still need loans to pay for their tuition.

Other difficulties I haven't listed include having to undergo a background check,
visa processing and interviews, as well as lack of experience in writing a personal
statement and curriculum vitae. Yet the difficulties involved in applying for a rotation
are only a fraction of the challenges for medical graduates from China wishing to
obtain graduate medical training in the U.S.

Still, after five months of U.S. rotations, I believe my experience has been so valuable
that it was worth all the effort. It has prepared me well for an American graduate
medical education, and I am now able to help other medical students in China and elsewhere
with the barriers I was able to overcome.

Chi Tang recently finished medical school and is now attending residency interviews.

ACP Hospitalist provides news and information for hospitalists, covering the major issues in the field. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated.